The most significant social fact about the US is that the
number of elderly people is going to increase dramatically. The
effects won't be seen in the next 10 years, because not many
babies were born in the late '30s and early '40s. In 25 years,
however, the peak of the baby boomers will reach retirement age,
and society will become predominantly age 65 or older. Obviously,
a much bigger fraction of the gross domestic product will have to
be spent on health care then. This might not be altogether a bad
thing because the percentage of elderly people who are not infirm
will probably also increase, and their contributions to society
may be increasingly significant.

Unfortunately, the business model for US medicine is broken,
and it may not be able to meet the challenges presented by an
aging population. Physicians are lamenting because they have to
deal with each patient's insurance coverage in planning a
treatment, and there are about 1600 different insurance carriers.
Patients are also generally unhappy because their doctors are too
harried to spend enough time explaining the rationale for the
treatments that they recommend. Finally, the people who pay for
health care, in their roles as stockholders and tax payers, are
alarmed because there is no apparent limit to the demand for
health care which, however, produces relatively little increase
in productivity and happiness at the margin.

Impact

The growing significance of information in health care, which
currently accounts for about 30% of every patient dollar, or
about $300B each year, is hard to overstate. Nevertheless, the
most obvious benefit of modern information technology - the
ability to electronically capture information as it is created
and subsequently reuse that information at negligible incremental
cost - has hardly begun to be realized in health care. It is
remarkable that, although people own their own medical records in
principle, only half of all states even guarantee the right of
citizens to receive their own records from health-care providers.

Electronic information technology is especially good at
sorting and compiling voluminous data and determining which
hypotheses about the data are statistically valid. The bigger the
sample, the more certain the conclusions can be. For the really
hard and important questions, it may be necessary to use all the
known facts. Current Internet usage and practice shows that it
would not be difficult to allocate server space for everyone's
medical records. The number of US adults using the Internet in
the first quarter of 1997 was estimated to be 40 to 45
million, which is already a substantial fraction of the
population. Morevoer, many Internet service providers throw in 5
or 10 megabytes of server space for free so that their customers
can experiment with personal web pages if they want to.

Ten megabytes is the equivalent of about 2 million words,
which could fill a small reference library. If that much data per
person were online for the entire population, it might be
possible to answer some difficult but very important questions.
For example, randomized controlled trials have been conducted to
assess the effectiveness of breast-cancer screening. An NIH
panel reviewed the available data and concluded that there is
still no proof that screening reduces mortality for women in
their 40's, even though breast cancer is the leading cause of
death for them. The implication is that the treatment that
usually follows a positive screen is ineffective in this group,
which is doubly regrettable because the treatments compound the
misery of the disease. Clearly more experimental treatments and
better statistics are urgently needed until better results are
achieved. There are also problems with the statistics associated
with the detection and treatment of prostrate cancer in men.

Solution

Medicine needs a repository segment that acts as an agent of
the people for whom it keeps records of medical services. The
records should be available anytime and anywhere there is a
legitimate need for them. The Internet can provide this
availability at reasonable cost. Of course, people will be
sensitive about their privacy at first. However, networking
medical records is merely an extension of computerizing them.
Privacy can be preserved with cryptographic techniques. The real
issue is who's interest does the holder of the records ultimately
represent?

The best way to make sure that complete records are kept may
be to require health-care providers to file them as a condition
of being reimbursed by insurance carriers. This might require
legislation, but many benefits would flow from the completeness
of the records that would result. One of the considerable direct
benefits would be that people could be reminded to make
appointments for routine or follow-up care or to have their
prescriptions refilled. The repository segment would also be an
ideal source of data for compiling statistics without
compromising individual privacy.